Operative Orthopadie Und Traumatologie最新文献

Objective: Aim of surgical treatment is the primary stabilization of the unstable elbow following a ligamentous elbow dislocation.

Indications: Ligamentous elbow dislocations are typically accompanied by injuries to the surrounding musculature and collateral ligaments of the elbow joint. Surgical treatment is indicated in case of failure of nonoperative therapy, i.e., when a dislocation can only be prevented in immobilization > 90° and pronation of the elbow or an active muscular centering of the elbow fails after 5-7 days.

Contraindications: Contraindications for a solely "internal bracing" augmented primary suture are generally in the case of accompanying bony injuries in elbow dislocations, extensive soft-tissue injuries, and septic arthritis of the elbow.

Surgical technique: The augmented primary suture of the elbow is performed using both a lateral (Kocher or Kaplan) and medial (FCU split) approach to the elbow. After reduction of the elbow, the collateral ligaments are first augmented with high-strength polyethylene suture and fixed in the distal humerus together with another high-strength polyethylene augmentation suture. The extensors and flexors are then fixed to the medial and lateral epicondyle, respectively, using suture anchors.

Postoperative management: The aim of the postoperative management is early functional exercise of the elbow. The elbow is placed in an elbow brace to avoid varus and valgus load.

Results: Between August 2018 and January 2020, a total of 12 patients were treated with an augmented primary suture following unstable ligamentous elbow dislocation. After a mean follow-up of 14 ± 12.7 months, the mean Mayo Elbow Performance Score was 98.5 points with a mean functional arc of 115°. None of the patients reported a recurrent dislocation or persistent instability of the elbow.

Objective: Computer navigation is used in patients with spine fractures to optimize the accuracy of pedicle screws and thereby reduce intra- and postoperative complications, such as injuries to vessels, nerves and accompanying structures. In addition, the ideal screw length and diameter for each pedicle can be detected to ensure optimal stability.

Indications: Intraoperative navigation is suitable for the treatment of spine fractures, which require dorsal stabilization or fusion. It is primarily used for dorsal procedures ranging from the cervical to lumbar/sacral spine.

Contraindications: Computer navigation relies on rigid fixation of the dynamic reference base (DRB) at the spinous process. Failure of DRB fixation is the major contraindication for navigation in the spine.

Surgical technique: After acquisition of an intraoperative three-dimensional (3D) scan, a digital relation between the anatomy and the 3D scan is established with the navigation system and its infrared camera. Pedicle screws are planned percutaneously with a calibrated pointer. In the next step K‑wires (or screws) are implanted after the pedicles are drilled with a calibrated drill guide. After implantation, an additional 3D scan is performed to verify accurate K‑wire placement.

Postoperative management: Postoperative management does not differ compared to nonnavigated procedures.

Results: Intraoperative navigation in combination with modern imaging systems leads to very high accuracy for pedicle screws. Immediate intraoperative control of K‑wires as well as screws and fracture reduction can avoid revision surgery. Image guidance can reduce radiation exposure for the surgical team.

Objective: Safe placement of posterior cervical-sacral pedicle screws, S2-Ala-iliac screws, iliac screws, transarticular screws C1/2, translaminar screws C2 or cervical lateral mass screws under the guidance of spinal navigation.

Indications: All posterior spinal instrumentations with screws: instabilities and deformities of rheumatic, traumatic, neoplastic, infectious, iatrogenic or congenital origin; multilevel cervical spinal stenosis with degenerative instability or kyphosis of the affected spinal segment.

Contraindications: There are no absolute contraindications for spinal navigation.

Surgical technique: Cervical spine: Prone position on a gel mattress, rigid head fixation, e.g., with Mayfield tongs; if appropriate, closed reduction under lateral image intensification; thoracic + lumbar spine: prone position on a cushioned frame; midline posterior surgical approach at the level of the segments to be instrumented; if necessary, open reduction; insertion of the cervical/upper thoracic screws under the guidance of spinal navigation; if necessary, posterior decompression; instrumentation longitudinal rods; if fusion is to be obtained, decortication of the posterior bone elements with a high-speed burr and onlay of cancellous bone or bone substitutes.

Postoperative management: In stable instrumentations, no postoperative immobilization with orthosis is necessary, removal of drains (if used) 2-3 days postoperatively (postop), removal of the sutures 14 days postop, clinical and x‑ray controls 3 and 12 months postop or in case of clinical or neurological deterioration.

Results: Numerous studies showed that the use of spinal navigation significantly reduces implant malplacement rates, complications, and revision surgery. Furthermore, intraoperative radiation exposure to the operation team can be reduced by up to 90%.

Objective: Puncture of large joints is performed for diagnostic purposes on the one hand and for the treatment of joint pathologies on the other. Puncture can be used for rapid pain relief by relieving effusions or intra-articular hematomas. The obtained puncture specimen allows immediate visual assessment and subsequent microscopic-cytological and microbiological evaluation in the laboratory.

Indications: The indication for puncture of a large joint is for diagnosis and/or therapy of inflammatory, traumatic or postoperative joint problems. Diagnostic punctures are used to obtain punctate, to differentiate the location of pain or (rarely) to apply contrast medium for magnetic resonance arthrography. Therapeutic punctures allow the injection of drugs or platelet-rich plasma (PRP) as well as the relief or drainage of effusions.

Contraindications: If there are inflammatory skin alterations-especially purulent inflammation-joint punctures through these lesions are absolutely contraindicated. Special attention is necessary if the patients are on anticoagulants.

Surgical technique: Absolute sterile handling is mandatory. Unnecessary pain can be avoided by a sterile skin wheal of local anesthesia, safe puncture points, and careful handling of the cannulas.

Postoperative management: Joint aspiration material has to be handled according to the local, intrahospital rules in a timely manner. Puncture sites are covered with sterile dressings, and if intra-articular medication is administered, the joints have to be passively moved through the range of motion to distribute the medication. Thereafter, compression therapy from distally to proximally while also covering the puncture site avoids recurrence of swelling or hematoma.

Facts: If sterile conditions are guaranteed, infections rarely occur (0.04-0.08%, 4-8/10,000 cases). The risk of false-positive detection of microorganisms is extremely low.

Objective: Safe and bone-conserving extraction of a well-fixed curved short stem without the necessity of a transfemoral approach.

Indications: The revision of a well-fixed curved short stem, for example, due to periprosthetic infection or malposition. Meticulous preparation of the cone and the lateral shoulder of the stem.

Contraindications: Correct placement of the chuck not possible.

Surgical technique: Choice of a standard approach to the hip joint. Luxation. Removal of the implanted head. Preparation of the proximal femur and removal of bone at the stem shoulder. Attachment of the chuck to the cone. Insertion of the "prestarter" chisels through the guided slots of the chuck, starting with the lateral chisel, followed by the ventral and dorsal chisel. The cut must point outwards away from the implant. Repetition of this procedure using the "starter" chisels in the same order. Removal of the chuck. Careful insertion of the "final" chisels in the same order. Trial of a stem extraction using an extraction tool. Optional repetition of the whole procedure. In order to avoid fractures, opening of the medial interface only after preparation laterally, ventrally and dorsally, by careful insertion of the medial chisels in the respective order alongside the calcar. Finally, extraction of the stem.

Postoperative management: Postoperative protocol according to the respective revision implants and fixation technique used.

Results: The described procedure has proven successful in clinical practice in the three author affiliations in a total of 14 cases. In 3 (21.4%) cases, despite the use of the extraction chisel system, an additional transfemoral approach or fenestration had to be performed to remove the short stem. Primary straight stems were used in over half of the cases (57.8%) as revision implants, whereas in 4 cases (36.4%) a cementless short stem could again be used.

Objective: Bridging the defect in chronic ruptures of the Achilles tendon via a turn-down flap of the aponeurosis sparing the skin of the rupture zone.

Indications: Chronic Achilles tendon rupture with a defect distance ≤ 6 cm.

Contraindications: Extended Achilles tendon defect interval ≥ 7 cm, chronic wounds or infections near the surgical approach, higher degrees of arterial or venous malperfusion, complex regional pain syndrome.

Surgical technique: Dorsomedial surgical approach proximal to the rupture zone, splitting of the crural fascia, loading of the distal Achilles tendon stump with a nonresorbable augmentation suture using the Dresden instrument, preparation of the turn-down flap of the aponeurosis securing the turning point with a catching suture. Transfer of the turn-down tendon flap under the skin bridge and suture to the distal tendon stump tying the augmentation suture under adequate pretension simultaneously closing the gap in the aponeurosis. Alternative technique: free advancement of the autologous tendon graft.

Postoperative management: Anterior splint in 20° of plantar flexion, consecutive mobilization and rehabilitation similar to the percutaneous technique in acute Achilles tendon rupture with the Dresden instrument. Lower leg orthosis with 20° of plantarflexion for 8 weeks, then stepwise reduction of the heel height. Physiotherapy beginning from the 2nd postoperative week, active full-range of ankle motion from 6 weeks after surgery.

Results: In general, worse results than in percutaneous reconstruction of acute Achilles tendon injuries. Despite this, high degrees of patient satisfaction with a low rate of postsurgical complications and good functional outcome with admittedly poor data availability. Relevant increase of plantar flexion strength depending on the amount of degeneration of the triceps surae muscle.

Objective: Reduction of pain and swelling over the Achilles tendon insertion while maintaining function.

Indications: Strong, intolerable pain over the Achilles tendon insertion with chronic, calcifying insertional tendinopathy that does not respond to non-operative treatment over a minimum of 6 months.

Contraindications: Chronic wounds or severe circulatory deficits at the foot or ankle, irradiating or projected pain, complex regional pain syndrome (CRPS).

Surgical technique: The intratendinous heel spur is resected via a lateral approach. The superior surface of the calcaneal tuberosity is trimmed by resection of the dorsal heel spur with the oscillating saw. A second osteotomy at the medial edge of the tuberosity extends to the insertion of the plantaris tendon. With the third osteotomy, the Haglund deformity is resected. At the resulting area with cancellous bone, the Achilles tendon is reinserted with a suture anchor.

Postoperative management: A ventral plastic splint in 20° plantar flexion is worn for a week. Full weight-bearing is allowed in a walking boot with 4 cm heel lift for 6 weeks. The heel lift is then gradually reduced for another 2 weeks. After 8 weeks only an elastic wedge of 1 cm is worn. Physical therapy (isometric exercises) starts in the boot and is intensified after removal of the boot.

Results: Seven of 12 patients treated with that technique for calcifying insertional Achilles tendinopathy (58%) stated being pain free according to the Likert scale, while the remaining 5 patients (42%) reported a "substantial improvement". The VISA‑A score averaged 84 of 100 points. Postoperative complications have not been observed.

Objective: Treatment of Achilles insertional calcific tendinosis through a longitudinal midline incision approach with optional resection of the retrocalcaneal bursa and calcaneal tuberosity (Haglund's deformity).

Indications: Calcific Achilles tendinosis, dorsal heel spur, insertional tendinosis.

Contraindications: General medical contraindications to surgical interventions. Fracture, infection.

Surgical technique: Longitudinal skin incision medial of the Achilles tendon. Exposure and midline incision of the Achilles tendon with plantar detachment from the insertion site preserving medial and lateral attachment. Resection of a dorsal heel spur and intratendinous calcifications. Optional resection of the retrocalcaneal bursa and calcaneal tuberosity (Haglund's deformity).

Postoperative management: Partial weight bearing 20 kg in 30° plantar flexion in a long walker boot for 2 weeks. Afterwards 2 weeks of progressively weight bearing in 15° plantar flexion and another 2 weeks in neutral ankle joint position in a long walker boot.

Results: A total of 26 feet of 26 patients with calcific Achilles tendinosis were treated with midline incision of the tendon. In all feet calcific tendon parts were resected. In 10 (38%) feet, a prominent dorsal spur was resected, in 12 feet (38%) retrocalcaneal bursa, and in 24 (92%) feet a calcaneal tuberosity. Mean follow-up was 34.5 months (range 2-64 months). Preoperative Manchester-Oxford Foot Questionnaire (MOXFQ) score was 58.2 (±8.1) and postoperatively the score was 22.75 (±6.0). In all, 7 (26.9%) patients stated delayed wound healing; 1 suffered from deep vein thrombosis. Shoe problems were reported by 50% of patients, and 23.1% suffered from par- or dysesthesia. No revision surgery was required.

Objective: Neutralizing a posteromedial rotatory instability (PMRI) caused by coronoid deficiency by restoration of the humeroulnar joint surface with an autologous iliac crest bone graft.

Indications: Surgery is indicated in patients with chronic deficiency of the anteromedial facet of the coronoid with subsequent PMRI.

Contraindications: Coronoid reconstruction is not recommended in patients with advanced osteoarthritis of the elbow caused by subluxation of the humeroulnar joint. General contraindications like acute infection, pregnancy and lack of operability should also be taken into account.

Surgical technique: First, a medial approach is established and the base of the coronoid is prepared. Afterwards an autologous iliac crest bone graft is placed onto the defect and secured by screws or a plate. In addition, a reconstruction of the anterior bundle of the medial collateral ligament with an autologous tendon graft is performed.

Postoperative management: An elbow orthesis is worn for 6 weeks after surgery to avoid valgus or varus stress. There is no restriction in range of motion. A continuous passive motion elbow chair supports the patient in regaining elbow mobility.

Results: Between 2015 and 2017, we treated 10 patients suffering from chronic coronoid defects with coronoid reconstruction. Eight of the patients were available for follow-up 86 weeks after surgery. The mean age was 41.4 years. In all patients, elbow range of motion and patient-related outcome measures were improved after surgery. Plain radiographs illustrated correct centering of the elbow joint. One patient had to undergo elbow arthroplasty and was excluded. Coronoid reconstruction with an autologous iliac crest bone graft restored humeroulnar joint congruency and improved satisfaction in patients suffering from chronic coronoid deficiency.

Objective: Restoration of the anatomy and the original length of the muscle-tendon unit in triceps tendon ruptures.

Indications: Acute and chronic triceps tendon ruptures with persisting symptoms and significant strength deficits.

Contraindications: Infections and tumors in the surgical area.

Surgical technique: Prone position. Skin incision over the distal triceps in a lateral direction around the olecranon. Mobilization of the tendon and débridement of the olecranon. Drilling of 2 × 2.9 mm suture anchor holes medial and lateral into the footprint of the olecranon. In addition, drilling through the olecranon 12 mm distal to the tip of the olecranon and transosseous introduction of 4 sutures. Then the suture anchors (all-suture or titanium anchors) are inserted into the drill holes. Refix the deep and superficial tendons with the anchor threads. Refix the upper tendon portions with the transosseous sutures. In the case of chronic lesions, a graft interposition is necessary.

Postoperative management: Dorsal 10 ° splint, then change to an orthosis fixed in 20 ° extension and passive mobility 0-30 ° flexion for 6 weeks. From the 7th week onwards, load-free, physiotherapeutically controlled increasing mobilization. Starting weight-loading from the 13th week on. Full load after 6 months.

Results: In all, 34 male strength athletes with acute triceps tendon rupture underwent surgery using the hybrid technique described and were prospectively recorded. The MEPS‑G score averaged 94.7 points, there were no permanent limitations in mobility, and the postoperative strength ability averaged 94% of the original strength performance ability. The return to sport achieved 100%. The complication rate was 20.6%. Reconstruction of the distal triceps tendon using hybrid technology leads to very good functional results. Half of all patients complained of symptoms even before the rupture, which suggests previous damage to the distal triceps tendon caused by degeneration.